What is the initial treatment approach for enteritis?

Initial Treatment of Enteritis

The initial treatment approach for enteritis depends critically on severity and patient immune status: uncomplicated cases require oral rehydration and supportive care, while complicated cases (with fever, dehydration, bloody stools, or immunocompromise) necessitate hospitalization with IV fluids, broad-spectrum antibiotics, and close monitoring.

Severity Stratification and Initial Assessment

The first step is determining whether enteritis is uncomplicated or complicated, as this dictates the entire treatment pathway 1.

Uncomplicated Enteritis

• Oral rehydration is the cornerstone of treatment 1
• Reduced osmolarity oral rehydration solution (ORS) is first-line therapy for mild to moderate dehydration 1
• Dietary modification and avoidance of skin irritation 1
• Loperamide (4 mg initially, then 2 mg after each loose stool, maximum 16 mg/day) for symptom control 1
• Notify treating physician but outpatient management is appropriate 1

Complicated Enteritis (Requires Hospitalization)

Complicated features include: fluid depletion, vomiting, fever, sepsis, neutropenia, bleeding, or severe dehydration 1.

Treatment Algorithm for Complicated Cases

Immediate Interventions (All Patients)

• IV fluid and electrolyte replacement to correct dehydration and electrolyte imbalances 1
• Potassium supplementation of at least 60 mmol/day (hypokalaemia can promote toxic dilatation) 1
• Low molecular weight heparin for thromboprophylaxis 1
• Correct anaemia if present 1
• Bowel rest in severe cases 1

Antibiotic Therapy Considerations

When to initiate antibiotics:

• Moderate to severe cramping with fever and diminished performance status 1
• Bloody diarrhea with fever documented in medical setting, abdominal pain, and signs of bacillary dysentery 1
• Recent international travel with temperature ≥38.5°C or signs of sepsis 1
• Immunocompromised patients with severe illness 1
• Suspected superinfection or intra-abdominal abscess 1

Empiric antibiotic choices:

• Fluoroquinolones (e.g., ciprofloxacin) OR azithromycin depending on local susceptibility patterns and travel history 1
• Metronidazole can be added for anaerobic coverage 1
• For infants <3 months: third-generation cephalosporin 1

Stool Evaluation (Complicated Cases)

• Complete blood count and electrolyte profile 1
• Stool work-up for blood, Clostridium difficile, Salmonella, E. coli, Campylobacter, and infectious colitis 1
• Multiplex antimicrobial testing is preferred over traditional stool cultures 2
• Fecal leukocytes or lactoferrin testing to confirm inflammatory etiology 1

Special Populations

Neutropenic Enterocolitis

This is a medical emergency with high mortality risk 1.

• Immediate broad-spectrum antibiotics covering enteric gram-negatives, gram-positives, and anaerobes 1
• Recommended regimens: piperacillin-tazobactam, imipenem-cilastatin, OR cefepime/ceftazidime plus metronidazole 1
• Granulocyte colony-stimulating factors (G-CSFs) 1
• Nasogastric decompression 1
• Serial abdominal examinations 1
• Avoid anticholinergic, antidiarrheal, and opioid agents as they may aggravate ileus 1
• Surgery reserved ONLY for perforation, ischemia, persistent bleeding, or clinical deterioration despite aggressive medical management 1

Inflammatory Bowel Disease (IBD) Patients

• Intravenous corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) for severe active disease if hemodynamically stable 1
• Concomitant IV metronidazole often advisable to distinguish active disease from septic complications 1
• Assess response by day 3; consider rescue therapy (infliximab or ciclosporin) if non-responsive 1
• Antibiotics NOT routinely administered unless superinfection suspected 1

Advanced Therapies for Refractory Cases

Octreotide

For severe, refractory diarrhea in complicated cases 1:

• Starting dose: 100-150 μg subcutaneously three times daily
• IV dosing: 25-50 μg/hour if severely dehydrated
• Escalate up to 500 μg subcutaneously three times daily until controlled 1

Nutritional Support

• Total parenteral nutrition appropriate in complex fistulating disease, severe malnutrition, or when enteral route contraindicated 1
• Elemental or polymeric diets as adjunctive therapy 1

Critical Pitfalls to Avoid

• Do NOT use antimicrobials for STEC O157 or Shiga toxin 2-producing strains as this may worsen outcomes 1
• Do NOT delay surgical consultation in neutropenic patients with bowel wall thickening >10 mm (60% mortality risk vs 4.2% if <10 mm) 1
• Do NOT use antidiarrheal agents in neutropenic enterocolitis 1
• Do NOT prescribe antibiotics empirically for uncomplicated watery diarrhea in immunocompetent patients 1
• Microbial studies are unnecessary for mild symptoms resolving within one week 2